This document discusses nerve injuries, including their classification, pathophysiology, rehabilitation, diagnosis, and treatment. It defines nerve injuries as interruptions of normal nerve physiology that affect nerve conduction. Nerve injuries are classified into degrees ranging from neurapraxia, which involves demyelination without axonal injury, to neurotmesis, which is a complete nerve division. The document outlines the various types of nerve injuries, their clinical presentations, and rehabilitation approaches, which may involve splinting, stimulation, and physical therapy over months to years. Surgical techniques for repair include primary repair, grafting, transfers, and conduits.

1. Nerve injury
Hamad emad dhuhayr
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

2. OUTLINE
 DEFINITION.
 TYPES OF NERVE INJURIES.
 FATE (pathophysiology) AND
REHABILITATION.
 ETIOLOGY.
 PRESENTATION.
 DIAGNOSIS.
 CLINICAL EXAMPLES:
(ERB’S,CARPAL TUNNEL,RADIAL,ULNAR,SCIATIC AND
PERONEAL N.)
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

3. DEFINITION
Partial or complete interruption of normal
physiology of the nerve.
NERVE CONDUCTION IS AFFECTED.
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

4. Classification Of Nerve
Injuries
 Seddon, Sunderland and lately by Mackinnon
 6 degrees

5. Degrees Of Nerve Injury
 1st
degree of injury(neuraparaxia)
 Segmental demylination
 Axons intact
 Recovery in 12 to 16 wks
 2nd
degree injury(axonotmesis)
 Axonal injury/ distal wallerian degeneration
 Regeneration at rate of 1 inch per month
 Complete slow recovery

6. Degrees Of Nerve Injury
 3rd
degree injury
 Axonal injury & fibrosis of endoneurium
 Incomplete recovery
 4th
degree injury
 Axonal injury
 Damage to endo and perineurium with
dense scarring
 Needs surgical intervention

7. Degrees Of Nerve Injury
 5th
degree injury(neurotmesis)
 Complete nerve division
 6th
degree injury
 Variable combination of previous
five degrees of nerve injury

9. FATE AND REHABILITATION
 WALLERIAN DEGENERATION
1 MM PER DAY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

10. REHABILITATION
 PAIN CONTROL.
 SPLINT. (AVOID PRESSURE SORES)
 NERVE AND MUSCLE STIMULATION.
 NEARBY JOINTS RANGE OF MOTION.
 MONTHS ----- YEARS .
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

11. Nerve Injury
 Focal contusion (gunshot wounds)
 Stretch/traction injury
 Drug injection injury
 Compression
 Crush injuries
 Avulsion
 Laceration
 Electrical burns
 Idiopathic
 Others(Viral infections, metabolic and neural disorders)

12. PERSENTATION
 PAIN
 LOSS OF SENSATION
 LOSS OF MOTION
 LOSS OF POWER
 LOSS OF REFLEXES
 WASTING
 TROPHIC CHANGES
(skin,sc,neurovascular,bones,muscles)
 CONTRACTURES
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

13. DiagnosisDiagnosis
 Motor functionMotor function
 Movements, muscle atrophyMovements, muscle atrophy
 sensory functionsensory function
 Tinel sign, Ten testTinel sign, Ten test
 Two point discriminationTwo point discrimination
 Touch, vibrationTouch, vibration
•HistoryHistory
•ExaminationExamination

14. Tinel Sign
 Tinel sign: -
 peripheral tingling or
dysaesthesia' provoked by
percussion of the nerve
 Positive in axonal injuries

15. Electrical Stimulation Tests:
 EMG
 NCS
 Intra operative nerve action potential

16. CLINICAL EXAMPLES
 ERB’ PALSY
 CARPAL TUNNEL SYNDROME(MEDIAN NV)
 RADIAL NERVE INJURY
 ULNAR NERVE INJURY
 SCIATIC NERVE INJURY
 LATERAL POPLITEAL NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

17. ERB’S PALSY
 BIRTH INJURY (DIFFICULT LABOUR)
 TRACTION ON NERVE ROOTS C5-6
 STRETCH-RUPTURE-AVULSION
 UPPER LIMB IN EXTENSION
 MOTHER NOTICE NO MOTION
 90% GOOD RECOVERY
 ROLE OF SURGERY AFTER 3 MONTHS
 REMEMBER PROPER REHABILITATION
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

18. CARPAL TUNNEL SYNDROME
 MEDIAN NERVE ENTRAPMENT BY FLEXOR RETINACULUM
PAIN,NUMBNESS,NIGHT
 MANUAL WORKERS
 DIAGNOSIS
 SURGERY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

19. RADIAL NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

20. ULNAR NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

21. SCIATIC NERVE INJURY
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

22. PERONEAL NERVE INJURY
(LPN)
 FOOT DROP
 TIGHT POP
 SKELETAL TRACTION
 DIRECT INJURY (RARE)
 DYNAMIC SPLINT
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

23. Principals Of Nerve Repair
 Microsurgical techniques
 Adequate magnification
 Microsurgical instruments & sutures
 Different techniques:
 Primary nerve repair
 Nerve grafting
 Nerve transfer
 Nerve conduits
 Nerve allografts

24. Timing Of The Nerve Repair
 Sharply transected nerves
 Immediate repair
 Crushed, avulsed, blast injuries
 Nerve ends tacked together
 Repair delayed for 3 weeks or until wound bed permits
 Re-exploration
 Neuroma excision, nerve grafts
 Acute nerve grafting in the 1st
sitting
 Bleeding control ,trimming of fascicles ,loose epineural suturing
 Closed injuries treated expectantly for 12 weeks

26. Primary Nerve Repair
 Primary nerve repair
 Epineural repair
 Grouped fascicular repair

27. Epineural Repair
Standard repair

28. Fascicular Repair
 Restore the continuity of fascicles
 Internal topography
 Intra-operative nerve stimulation
 Neurolysis with the eyes
 Priority to the motor recovery(radial
and peroneal nerve)

30. e.g. Ulnar Nerve Fascicular
Components

31. Nerve Grafts
 Tension at site of repair
 Need of postural positioning
 Alignment of sensory & motor components
 Maximize number of axons
 Reversal of graft
 Exclusion of expendable nerve

32. Options For Nerve Grafts
 Sural nerve
 30-40cm
 Lateral peroneal communicating br : 10-20cm
 Lateral antebrachial cutaneous nerve(LABC)
 8cm
 Medial antebrachial cutaneous nerve (MABC)
 Anterior & posterior division
 20 cm
 Expendable nerves(peroneal and radial)
 Sensory branches of ulnar and median nerves
 Distal anterior interosseous nerve and so on…

33. Disadvantages
 Donor site scarring
 Donor site sensory loss
 Patient education

34. Neuroma In Continuity
Complete : resection and repair with graft

36. Neuroma In Continuity
 Incomplete neuroma
 Intra-operative nerve stimulation
 Black boxing around neuroma

38. Nerve Transfer
 Indications:
 Very proximal peripheral nerve injuries
 Root avulsions
 Excessive scarring
 Level of injury unclear
 Idiopathic neuritides
 Radiation induced nerve injury

39. Nerve Transfer
 Motor nerve transfer
 Pure motor axons
 Close proximity
 expendable
 Synergistic supply
 Sensory nerve transfer
 pure sensory axons
 Innervates non critical area
 Expendable and lying in close proximity

40. Most Common Uses Of Nerve
Transfer
 elbow flexion
 Shoulder abduction
 Ulnar-innervated intrinsic hand function
 Forearm pronation
 Radial nerve function

41. Transfer of radial nerve to axillary nerve

42. Nerve Conduits
 Veins, pseudo-sheaths,
bioabsorbable tubes
 short nerve gaps ≤ 3cm
 Low antigenicity , biodegradability
 Trials to add a nerve graft inside the
conduit
 neurotrophic factors

44. Nerve Allografts
 Extensive injuries
 Limited donor material
 Immunosuppressive agents
 FK506( tacrolimus )
 Prednisone , azathioprine
 Processed acellular cadaveric nerve allografts
 AxoGen, Inc. ,Alachua, FL.

46. Summary
 Axon degeneration occurs from mild
compression injury
 The prognosis for Neuropraxia is poor
 Axonotmesis is generally caused from
separation of the cell body from the neuron
 Wallerian Degeneration typically does not occur
in Neuropraxic injury
 Surgical reconstruction is necessary in
Neurotmesis
 Wallerian Degeneration does not occur in
Neurotmesis
 A ligamentous structure can cause Neuropraxia
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby

47. Refferences
 Special surgery matary
Dr Saleh WaslAllah Alharby
www.ksu.edu.sa/DrSalehAlharby